Reducing drug related deaths: a pre-implementation assessment of knowledge, barriers and enablers for naloxone distribution through general practice.

BACKGROUND: The Scottish Naloxone Programme aims to reduce Scotland's high number of drug-related deaths (DRDs) caused by opiate overdose. It is currently implemented through specialist drug services but General Practitioners (GPs) are likely to have contact with drug using patients and their families and are therefore in an ideal position to direct them to naloxone schemes, or provide it themselves. This research gathered baseline data on GP's knowledge of and willingness to be involved in DRD prevention, including naloxone administration, prior to the implementation of primary care based delivery. METHODS: Mixed methods were used comprising a quantitative, postal survey and qualitative telephone interviews. A questionnaire was sent to 500 GPs across Scotland. An initial mailing was followed by a reminder. A shortened questionnaire containing seven key questions was posted as a final reminder. Telephone interviews were conducted with 17 GPs covering a range of demographic characteristics and drug user experience. RESULTS: A response rate of 55% (240/439) was achieved. There was some awareness of the naloxone programme but little involvement (3.3%), 9% currently provided routine overdose prevention, there was little involvement in displaying overdose prevention information (<20%). Knowledge of DRD risk was mixed. There was tentative willingness to be involved in naloxone prescribing with half of respondents willing to provide this to drug users or friends/family. However half were uncertain GP based naloxone provision was essential to reduce DRDs.Factors enabling naloxone distribution were: evidence of effectiveness, appropriate training, and adding to the local formulary. Interviewees had limited awareness of what naloxone distribution in primary care may involve and considered naloxone supply as a specialist service rather than a core GP role. Wider attitudinal barriers to involvement with this group were expressed. CONCLUSIONS: There was poor awareness of the Scottish National Naloxone Programme in participants. Results indicated GPs did not currently feel sufficiently skilled or knowledgeable to be involved in naloxone provision. Appropriate training was identified as a key requirement.

Competitive environments sustain costly altruism with negligible assortment of interactions.

Competition hinders the evolution of altruism amongst kin when beneficiaries gain at the expense of competing relatives. Altruism is consequently deemed to require stronger kin selection, or trait-selected synergies, or elastic population regulation, to counter this effect. Here we contest the view that competition puts any such demands on altruism. In ecologically realistic scenarios, competition influences both altruism and defection. We show how environments that pit defectors against each other allow strong altruism to evolve even in populations with negligible kin structure and no synergies. Competition amongst defectors presents relative advantages to altruism in the simplest games between altruists and defectors, and the most generic models of altruistic phenotypes or genotypes invading non-altruistic populations under inelastic density regulation. Given the widespread inevitability of competition, selection will often favour altruism because its alternatives provide lower fitness. Strong competition amongst defectors nevertheless undermines altruism, by facilitating invasion of unrelated beneficiaries as parasites.

Cost/Benefit considerations for recent saltcedar control, Middle Pecos River, New Mexico.

Major benefits were weighed against major costs associated with recent saltcedar control efforts along the Middle Pecos River, New Mexico. The area of study was restricted to both sides of the channel and excluded tributaries along the 370 km between Sumner and Brantley dams. Direct costs (helicopter spraying, dead tree removal, and revegetation) within the study area were estimated to be $2.2 million but possibly rising to $6.4 million with the adoption of an aggressive revegetation program. Indirect costs associated with increased potential for erosion and reservoir sedimentation would raise the costs due to increased evaporation from more extensive shallows in the Pecos River as it enters Brantley Reservoir. Actions such as dredging are unlikely given the conservative amount of sediment calculated (about 1% of the reservoir pool). The potential for water salvage was identified as the only tangible benefit likely to be realized under the current control strategy. Estimates of evapotranspiration (ET) using Landsat TM data allowed estimation of potential water salvage as the difference in ET before and after treatment, an amount totaling 7.41 million m(3) (6010 acre-ft) per year. Previous saltcedar control efforts of roughly the same magnitude found that salvaged ET recharged groundwater and no additional flows were realized within the river. Thus, the value of this recharge is probably less than the lowest value quoted for actual in-channel flow, and estimated to be <$63,000 per year. Though couched in terms of costs and benefits, this paper is focused on what can be considered the key trade-off under a complete eradication strategy: water salvage vs. erosion and sedimentation. It differs from previous efforts by focusing on evaluating the impacts of actual control efforts within a specific system. Total costs (direct plus potential indirect) far outweighed benefits in this simple comparison and are expected to be ongoing. Problems induced by saltcedar control may permanently reduce reservoir capacity and increase reservoir evaporation rates, which could further deplete supplies on this water short system. These potential negative consequences highlight that such costs and benefits need to be considered before initiating extensive saltcedar control programs on river systems of the western United States.

Modelling consultation rates in infancy: influence of maternal and infant characteristics, feeding type and consultation history.

BACKGROUND: Severity of illness, sociodemographic factors, and breastfeeding have been identified as predictors of consultation rates in infants, and prescriptions for antibiotics have been found to increase future consultation rates in older children. The Baby Check trial (1996-1998) provided detailed information about consultations for 935 babies during their first 6 months. AIMS: To investigate potential predictors of consultation rates in babies. DESIGN OF STUDY: A 6-month cohort study of newborn babies originally enrolled into a randomised controlled trial. Maternal and infant characteristics were collected from hospital discharge records. Primary care consultation data for each baby were collected by case note review. SETTING: Thirteen general practices in Glasgow. METHOD: Multilevel models were used to analyse the number of consultations for each baby during its first 26 weeks, dependent upon the baby's age, the calendar month, maternal and infant characteristics, and previous consultations. RESULTS: The strongest predictors of consultation rates were previous consultations, particularly during the preceding week. Breastfed babies and those with older mothers consulted less often. A multilevel model was better than a fixed effects model, with considerable variation in consultation rates between babies. CONCLUSION: Infants' consultation rates over time can be analysed using multilevel models, if details of primary care consultations are available. These models can incorporate the effects of fixed variables and those that change during the follow-up period. Our findings add to previous research linking breastfeeding with reduced morbidity in infancy, and for that reason breastfeeding should continue to be promoted in primary care.

Four case studies in state-supported telemedicine initiatives.

Four case studies were conducted in Georgia, Pennsylvania, Ohio, and Wisconsin to uncover factors that played key roles in state telemedicine initiatives. Factors that affect the success of state telemedicine initiatives include telecommunications infrastructure, correctional facilities, need for a champion, user buy-in, competition in the healthcare market, timing of the government's action, and financial support for the initiatives. How these factors affect state telemedicine networks, the level of importance of the various factors, and potential state actions to leverage or dampen the effects of the various factors are reviewed.

Computerized tomography tailored for the assessment of microscopic hematuria.

PURPOSE: We report the results of a multicenter study of arterial, corticomedullary, nephrographic and excretory phase helical computerized tomography (CT) for detecting and characterizing abnormalities causing asymptomatic microscopic hematuria. MATERIALS AND METHODS: We evaluated 350 consecutive patients, including 216 men and 134 women 23 to 88 years old, with asymptomatic microscopic hematuria of undetermined cause at 4 medical centers. Patients with known urological pathology were excluded from study. We performed 4 helical CT sequences, including pre-enhancement phase imaging from kidney to symphysis pubis, arterial phase imaging of the kidney and lower pelvis, corticomedullary nephrographic phase imaging of the kidney and lower pelvis, and excretory phase imaging from kidney to symphysis pubis with 2 to 5 mm. collimation and 1 to 1.5 pitch. RESULTS: Of 171 proved lesions 158 were correctly diagnosed. There were 10 false-positive and 13 false-negative diagnoses, indicating 0.9239 sensitivity, 0.9441 specificity, 0.9404 positive and 0.9285 negative predictive values, (p <0.001). All cases of congenital renal lesions, calculous disease, ureteral lesion and neoplastic lesion of the bladder were correctly diagnosed, as were 40 of 41 inflammatory renal, 21 of 23 renal masses and 13 of 16 inflammatory bladder lesions. In 27 patients with renal calculi the study was limited to pre-enhancement spiral CT. CONCLUSIONS: A positive diagnosis rate of 45.1% (158 of 350 cases) for the causes of heretofore refractory cases of hematuria with high sensitivity and specificity attest to the effectiveness of our hematuria CT protocol and support its use.